november-december 2014 • vol 61 • num 2 - hfma nj · 2015-01-18 · nj chapter, p.o. box 6422,...

November-December 2014 • vol 61 • num 2

new jersey chapter

QUALITY SERVICE AND EXTRAORDINARY INSIGHT IS PART OF OUR DNA

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November-December 2 0 1 4

Focus 1

focus•advertisers•focus•features•

focus•points•

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AmeriHealth NJ

ARMC & BPS Strategies

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CBIZ KA Consulting Services, LLC

First Credit Services, inc.

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Who’s Who in the Chapter ...... 2

The President’s View by Tracy Davison-DiCanto ............. 3

Certification Corner ................ 14

New Members .......................... 19-20

Who’s Who in NJ Chapter Committees ........... 21

Focus on Finance .................... 24

Job Bank Summary ................ 25

Mark Your Calendar ................ 32

36th Annual Institute Wrap Up by Jenniver Vanegas and Michael P. McKeever, CPA ..................................................... 6

NJHFMA Celebrates Our 2013-3014Award Recipients ............................................................................................ 10

Data Breaches Highlight Value of Medical Data by Alex Wozniak .......................................................................................................... 12

Once an Overpayment, Forever an “Obligation”The ACA’s 60-Day Rule Makes Murky Businessof “Identifying” Overpayments by Leonardo M. Tamburello, Esq. .................................................................................. 16

The Nicholson Foundation Continues to Partner with andSupport the New Jersey Health Care Quality Instituteand Medicaid ACO Demonstration Project by Dave Knowlton ........................................................................................................ 22

Stabilizing Health IT Expenditures While MaximizingProductivity by Jennifer Vanegas .................................................................................................... 26

Welcome to the Education Committee by Michael P. McKeever, CPA, CHC, CHRC ..................................................................... 27

Utilization of Healthcare Services Special ReportRedefining Care for our Communities by Jeff Hoffman .......................................................................................................... 29

You and Your 340B Program:Are You Compliant or Confused? by Venson Wallin and Bill Bithone;y, MD ........................................................................ 33

In Memory of John P. Sheridan .............................................................. 36


2 Focus

focus/hfmaWho’s Who in the Chapter 2014-2015Chapter Website …………………………………..www.hfmanj.org

Communications CommitteeBrian Herdman, Director ......................................................................CBIZ KA ConsultingElizabeth G. Litten, Esq., Chair ........................................................... Fox Rothschild LLPAl Rottkamp, MBA, Vice Chair ............................................. Princeton Healthcare SystemAnthony F. Consoli ................................................................... CBIZ Benefits & InsuranceMark Dougherty, FACHE .................................................................................... GI EnergyLaura Hess, FHFMA ............................................................................................ NJHFMAJohn Manzi ................................................................ Panacea Healthcare Solutions, LLCRhonda Maraziti .....................................................................WithumSmith + Brown, P.C.Nicole K. Martin, MPH, Esq. ..................................................................... Martin Law, LLCWilliam McCann ................................................................................................HealthfirstDavid A. Mills ..............................................................................Hinduja Global SolutionsAmina Razanica .............................................................New Jersey Hospital AssociationJames A. Robertson, Esq. ..........................McElroy, Deutsch, Mulvaney & Carpenter, LLPRoger D. Sarao, CHFP ................................................... New Jersey Hospital Association

NJ HFMA Chapter OfficersPresident, Tracy Davison-DiCanto, MBA , FHFMA ..................Princeton Healthcare SystemPresident-Elect, Heather Weber ...................................................................ParenteBeard Treasurer, Dan Willis ...................................................... Sutherland Healthcare SolutionsSecretary, Scott Mariani ........................................................... WithumSmith + Brown, P.C.

NJ HFMA Board MembersBrian Herdman – Associate Board Member .......................................... CBIZ KA Consulting

Scott Besler ..............................................................................................Besler Consulting

Stacey Bigos ....................................................................New Jersey Hospital Association

Steve Bilsky .............................................................................................................. Causey

Megan Byrne ..................................................................................................Ernst & Young

Kevin Joyce .....................................................................................................QualCare Inc.

Michael McKeever .............................................................Saint Peter’s University Hospital

Rosemary Nuzzo .................................................................................................Atlanticare

Josette Portalatin ...................................................................................The Valley Hospital

Roger Sarao, CHFP – Ex-Officio .......................................New Jersey Hospital Association

Jennifer Shimek – Associate Board Member ........................................ Ernst & Young, LLP

Stella Visaggio, FHFMA, CPA .....................................................Hackettstown Regional MC

Erica Waller ........................................................................... Princeton Healthcare System

NJ HFMA Advisory CouncilDavid J. Wiessel ................................................................................... Ernst & Young, LLPJohn Brault, FHFMA ................................................................................................ AetnaMichael Alwell, FHFMA ...........................................................................Barnabas Health Mary T. Taylor, MBA, FHFMA .......................................... Southern Ocean Medical Center

Advertising Policy/Annual RatesThe Garden State “FOCUS” reaches over 1,000 healthcare professionals in various fields. If you have a product or service you would like the healthcare financial industry to know

about, please take advantage of this great opportunity!Contact Laura Hess at 888-652-4362 to place your ad or receive a copy of the Chapter’s advertising policy. The Publications Committee reserves the right to refuse any ad not consistent

with the overall mission of the Chapter. Inclusion of an ad in this Newsmagazine does not infer endorsement of the product or service by the Healthcare Financial Management Association or the Publications Committee. Neither the Healthcare Financial Management Association nor the Publications Committee shall be responsible for slight variations in production quality of published advertisements. Effective July 2006 Rates for 5 bi-monthly issues are as follows:

Ads should be submitted as print ready (CMYK) PDF files along with hard copy. Payment must accompany the ad. Deadline dates are published for the Newsmagazine. Checks must be payable to the New Jersey Chapter - Healthcare Financial Management Association.

DEADLINE FOR SUBMISSION OF MATERIAL Issue Date Submission Deadline January December 1 April February 28 June April 30 October July 15 December October 15

IDENTIFICATION STATEMENTGarden State “FOCUS” (ISSN#1078-7038; USPS #003-208) is published bimonthly by the New

Jersey Chapter of the Healthcare Financial Management Association, c/o Elizabeth G. Litten, Esq., Fox Rothschild, LLP, 997 Lenox Drive, Building 3, Lawrenceville, NJ 08648-2311

Periodical postage paid at Trenton, NJ 08650. POSTMASTER: Send address change to Garden State “FOCUS” c/o Laura A. Hess, FHFMA, Chapter Administrator, Healthcare Financial Management Association, NJ Chapter, P.O. Box 6422, Bridgewater, NJ 08807

OBJECTIVEOur objective is to provide members with information regarding Chapter and national activities, with

current and useful news of both national and local significance to healthcare financial professionals and as to serve as a forum for the exchange of ideas and information.

EDITORIAL POLICY Opinions expressed in articles or features are those of the author(s) and do not neces-sarily reflect the view of the New Jersey Chapter of the Healthcare Financial Management Association, or the Communications Committee. Questions regarding articles or features should be addressed to the author(s). The Healthcare Financial Management Association and Communications Committee assume no responsibility for the accuracy or content of any articles or features published in the Newsmagazine. The Communications Committee reserves the right to accept or reject contributions whether solicited or not. All correspondence is assumed to be a release for publication unless otherwise indicated. All article submissions must be typed, double-spaced, and submitted as a Microsoft Word document. Please email your submission to:Elizabeth G. Litten, Esq. [email protected]

REPRINT POLICY The New Jersey Chapter of the HFMA will not reprint articles published in Garden State FOCUS Newsmagazine. Individuals wishing to obtain reprint authorization must obtain it directly from the author(s) of the article. The cover of the FOCUS may not be used in the reprint; however, the reprint may note that the article was published in a specific issue. The reprint may not imply endorsement by the HFMA, directly or indirectly.

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The President’s View . . .

Tracy Davison-DiCanto

Hello everyone –

The chapter year is half-over! Time flies when we are busy having fun putting on great events.

I hope that many of you were able to join us for this year’s Annual Institute held in October. It was an amazing success again this year. I would like to take this opportunity to thank the Institute Chairs – Jennifer Vanegas, Michael McKeever and Erica Waller for all of their efforts and dedication to making this year’s event as amazing as it was. They were supported by an incredible committee of chapter volunteers who ensured that every detail of the event went off without a hitch. I cannot thank each and every one of you enough for making my Presidential year Institute so memorable.

The Annual Institute had over 480 attendees from around the industry and across the tri-state area. A special thank you to all of our vendor sponsors who supported us this year, we truly appreciate all of your consideration and dedication to all of our chapter events. Our Make-A-Wish charity event raised $11,195 which will allow us to grant two wishes for deserving children. Stay tuned for the stories behind those children in a future issue…

I feel that it is important to take a moment to acknowledge and recognize Cooper Health System in this issue. The health system and the healthcare industry in New Jersey lost a recognized, dedicated leader and his wife on Sunday, September 28. John P. Sheridan Jr., Cooper’s President and CEO assisted in transforming the healthcare system and community redevelopment in Camden. In a statement issued by the health system, “There was never a day that went by when he wasn’t focused on what Cooper could do to help revitalize a city that he loved.” The healthcare industry in and around the Camden area will continue to feel his impact and benefit from the programs and changes he instituted during his tenure at Cooper. The leadership team of the Chapter and the Chapter extend our condolences and deepest sympathies to our friends and colleagues at Cooper Health System.

As we come into the holiday season and the New Year, I would like to wish all of you a very safe and happy holiday season and a wonderful New Year. We look forward to continuing to provide opportunities for you to develop both professionally and personally in 2015.” New Year’s Day. A fresh start. A new chapter in life waiting to be written. New questions to be asked, embraced, and loved. Answers to be discovered and then lived in a year of delight and self-discovery. Today carve out a quiet interlude for yourself in which to dream, pen in hand. Only dreams give birth to change. - Sarah Ban Breathnach

Don’t forget to check the website at www.hfmanj.org for upcoming events. Our January education session on Tuesday, January 13 hosted by our Patient Financial Services and Patient Access Forums and the March education session on Tuesday, March 10 hosted by our CARE and Physician Practice forums are not to be missed! Keep an eye out for webinar opportunities and the release of the agenda for the 2015 Women’s Session on April 16.

Warm regards –

Tracy Davison-DiCanto

The Communications Committee would like

to wish our fellow NJHFMA members a wonderful holiday

season

May this Joyous Season

bring you peace,

health,

and happiness

throughout the coming

year

Brian Herdman, Elizabeth Litten, Al Rottkamp, Tony Consoli, Mark Dougherty, Joe Fallon, Laura Hess, John Manzi,

Rhonda Maraziti, Nicole Martin, Bill McCann, David Mills, Amina Razanica, and Jim Robertson


6 Focus

38th Annual Institute Wrap Up

Jennifer Vanegas

by Jennifer Vanegas, Annual Institute Committee Chair &Michael P. McKeever, CPA, Annual Institute Committee Co-Chair

Once again, this October the members gathered at the Borgata for the NJ/Metro Philadelphia HFMA Annual Institute. This was the 38th anniversary of the event, and from the initial feedback, the attendees were once again impressed by the breadth of the educational offerings as well as the excellent networking opportunities. The Annual Institute has traditionally been the premiere event of the Chapter Year, which involves several committees and a core of dedicated volunteers to produce. This year’s event offered attendees up to 17.5 Continuing Professional Education hours.

Wednesday’s program began at 10:00 am with an interesting discussion entitled Top 4 Healthcare Challenges in 2014/2015 that was presented by Lyman Sornberger, Capio Partners’ Chief Strategy Officer. This presentation coincided with HFMA’s annual theme, “Leading the Change”. Following Lyman’s thought provoking comments, the attendees learned of a new and innovative player in the health insurance market, Oscar Insurance. Mario Schlosser, one of the founders of the company, explained how Oscar is leveraging technology to enhance the user’s experience and perhaps improve the efficiency of the healthcare delivery system.

After the two morning General Sessions, lunch was served in the Exhibitor Hall. Included with lunch was the Chapter’s Annual Awards Ceremony. As usual, members received a number of awards, including 5 Yerger Awards, 2 Platinum, 3 Gold, 4 Silver and 4 Bronze Founders Awards. There were also 3 Founders Medal of Honor recipients, 2 President’s Award winners, and 2 recipients of the Whatever it Takes

Award. This last award, won by Deb Carlino and Sandy Gubbine, is given in special recognition of a member in a non-leadership position who goes above and beyond the call of duty in support of the Chapter.

The afternoon allowed participants to choose between 15 sessions from various tracks presented during 3 breakout sessions. During the first session, the attendees had their choice between an update on the new model for revenue recognition; learning the ins and outs of establishing fair market value for physician compensation while remaining in compliance with Stark and the Anti-Kickback Statute; complying with the Two Midnight Rule through recognizing the appropriate level of care; how one major payer views patient-centered, value-based programs; and how to manage the risks inherent in focus arrangements with physicians. Participants in the Vendor Demo sessions got a chance to win an iPad, courtesy of First American Healthcare Finance.

This year’s Annual Institute also included something new, our Vendor Demo Sessions. These sessions, which did not qualify for CPEs, allowed our sponsors to interact with providers in a controlled setting. They were able to demonstrate their latest tools and services which are often difficult to discuss in the busy Exhibitor Hall. The sessions coincided with the breakout sessions, and were all held in Boardroom 2. On Wednesday, Capio Partners, BESLER Consulting and GAFFEY Healthcare hosted these sessions.

Mid-afternoon breakout sessions included an update on the proposed changes to not-for-profit healthcare entity finan-cial statements; a discussion on controlling physician device costs through the use of key performance indicators; regula-tory compliance in hospital/physician alignment strategies; en-hanced denial management through legal education; and how

Mike McKeever

Focus 7

to evaluate and implement an automated accounts payable process. The final presentations of the day included a discus-sion of the effects of the Affordable Care Act on New Jersey Medicaid and Charity Care; Part B medical billing; how to keep the revenue you’re entitled to; managing cost trends; and strategic forecasting for healthcare providers.

Wednesday evening, from 6:00 to 9:00 pm, the Chapter hosted the Annual Charity Event in the Exhibitor Hall. The evening included a buffet dinner followed by a silent auction. The attendees had their pick of prizes, both large and small, to win. Once again, the Make-A-Wish Foundation of New Jersey was the beneficiary of our members’ generosity. I am happy to report that we raised $11,195 which was enough to grant two children’s wishes this year. This was our second year in a row being able to grant two wishes! A special thanks to those who assisted in the solicitation of gifts for the Silent Auction, as well as our friends and supporters who donated so many great gifts. We would also like to thank all of our wonderful and generous members who bought additional tickets in support of the event.

Thursday morning began bright and early with a few words from Jennifer Vanegas, the Annual Institute Chair. Jennifer thanked the Institute committee for all of their hard work and dedication. She also thanked the Vendor Demo presenters and our other sponsors, without whose support the Institute would not be possible. Tracy Davison-DiCanto, Chapter President, then took the stage to discuss HFMA National’s theme for the current year, “Leading the Change”. Through various initiatives on the national and local levels, coupled with the educational events that our Chapter is known for, attendees appreciate their role in the emerging healthcare landscape.

Our second General Session presenter on Thursday morning was supposed to be Day Egusquiza, who is no stranger to NJ HFMA or to the Annual Institute. Unfortunately, Day was not able to join us this year, due to a last minute family illness. Tracy did let her know that she and her family were in our thoughts. A last minute replacement was Mark Dubow and Brandon Klar from The Camden Group, who were originally scheduled to present a breakout session but who agreed to fill in the open General Session. They discussed

the process of achieving operational efficiencies, using case studies as examples.

The Thursday morning agenda was rounded out with our first Keynote Speaker, Michael Josephson, a former lawyer, law professor and successful entrepreneur, who is a well-known speaker on the topics of ethics and character. Michael spoke to the audience about the importance of ethics in both our professional and personal lives. Using examples from public life, as well as his poem, What Will Matter, he left the audience thinking about their individual legacies, and what brings value to them, their families, and their colleagues.

After the first Keynote Speaker, and while lunch was being served in the Vendor hall, 4 separate Lunch & Learn sessions were occurring in the breakout rooms. There were presentations on successful physician integration strategies, an insider’s view of the OIG Hospital Compliance Review process, the financial impact of readmissions and the impact of quality reporting on healthcare providers.

This year the Annual Institute included 2 Keynote Speakers, so after lunch the attendees heard the true but hard to believe story of LabMD, from its founder and CEO, Michael Daugherty. LabMD was a small clinical laboratory company that allegedly had data removed from their servers by a private cyber security company. What happened next seems unreal, and if you didn’t know this was a true story you would think it was continued on page 8

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continued from page 7

the plot for a high tech novel. Michael wrote a book about his experiences, “The Devil Inside the Beltway”, and as healthcare executives I’d recommend that all healthcare executives read this cautionary tale. Michael’s goal now is to alert as many of us in the healthcare community that he can, while the final disposition of his case works its way through the administrative hearing process.

Thursday afternoon also included 3 series of breakout sessions, as well as 3 Vendor Demo sessions. The first breakout sessions included presentations on maximizing collections through revenue cycle improvement; a healthcare tax update; the Physician Payment Sunshine Act; the Patient Protection and Affordable Care Act; and new wage index delineations, opportunities and questions. The second sessions included discussions focused on controlling costs by working closely with your physicians; using Enterprise Risk Management principles when managing your investment program; issues related to workmen’s compensation and Personal Injury Protection payments to providers; and the advantages to using cogeneration to produce heat and power for your facility.

The final breakout sessions on Thursday afternoon included discussions of using big data to enhance your revenue cycle per-formance; the increased utilization of bundled payments using case studies; compliance risks related to the use of electronic

health records; protecting accounts receivable during system conversions; and innovative benchmarking techniques to improve performance. The afternoon’s Vendor Demo Sessions were presented by Com-merce Bank, Alpha Sys-tems and MediTract.

Thursday evening from 6:00 to 8:00 pm was reserved for the President’s

Reception, which was held at the Borgata Pool. For those who have never been, the President’s Reception is the social highlight of the Chapter year, held this year in the dramatic space surrounding the hotel’s indoor pool. We had great weather which allowed quite a few of the participants the opportunity to wander outside and enjoy the magnificent gardens. The food, music, atmosphere and great conversation created a memorable evening for all.

Another Annual Institute tradition is the after party, which was held at the MIXX Nightclub from 10:00 pm until late in the night. This year we had the BSTREETBAND and they were fantastic! Many of our members came out for the event and networked, had a few drinks and took their rightful spots on the dance floor. This party kept roaring until the very end and we were happy to see so many people having a great time.

To wrap up the Annual Institute, on Friday morning there were 2 General Sessions and a Panel Discussion. To kick

the morning off, there was a 2015 Health Care Regulatory Update, preparing the attendees for those changes that we can anticipate in the coming fiscal year. The second session focused on maximizing the return on your IT investment, which was timely as providers anticipate the next steps in achieving meaningful use. And finally, the Panel discussion, which included speakers with extensive knowledge of the healthcare marketplace and where it’s been, shared their visions as to where we’re going. While not always in agreement, the future most definitely lies somewhere within their shared visions.


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Finally, we need to thank those members who worked so hard to make this year’s Annual Institute a success by reviewing abstracts, acting as room monitors, identifying sponsors, soliciting gifts for the Charity Auction, and planning and preparing for the various events that took place throughout the 3 days at the Borgata. In no specific order they are Dan Willis, David Chin, Deb Carlino, Fred Molinari, Heather Stanisci, Christine Gordon, Stacey Bigos, Rita Romeu, Alyssa Madeira DiSalvatore, Christy Paul, BJ Welsh, Lisa Hartman, Tim Nugent, Dorothy DeLuca, Jennifer Shimek, Erica Waller, Sandy Gubbine, Mary Cronin, Heather Weber, Lew Bivona, Deb Shapiro, Pete DiCanto, Allison Kimowitz, Roe Nuzzo, Maria Facciponti, and Tracy Davison-DiCanto. And finally, many thanks go to Laura Hess, our Chapter Administrator, who is such an invaluable resource in everything we do.

We look forward to delivering an even better experience for our members next year, at the 39th NJ/Metro Philadelphia HFMA Annual Institute. We are working on some exciting new ideas and can’t wait to share them with you in 2015! Stay tuned…


10 Focus

Founders Awards

Folmer Bronze Reeves Silver Muncie GoldJoseph C. Wolak B.J. Welsh, FHFMA JaneAnn Sheehan, CHE

Stacey Bigos James A. Robertson, Esq Heather Lynn Weber

Josette A. Portalatin Eric S. Fishbein, FHFMA Michael P. McKeever, CPA

Christine A. Gordon Erica Waller

Medal of Honor Recipients Platinum AwardLewis D. Bivona, Jr., CPA, AFE John Brault, FHFMA

Mary M. Cronin, FHFMA Tracy Davison-DiCanto, FHFMA

Deborah E. Shapiro, MBA

2013-2014 President’s Award 2013-2014 Whatever It Takes AwardDan Willis Sandy Gubbine

Michael P. McKeever, CPA Deborah Carlino

2013-2014 Yerger AwardsYERGER - Institute Tracy Davison-DiCanto, Michael P. McKeever,

Dan Willis, Erica Waller, Jennifer Vanegas

YERGER - Make a Wish David Wiessel

YERGER - FACT Megan Byrne & Karen Henderson

YERGER - Physician Practice Forum Jennifer Shimek & Michael P. McKeever

YERGER - Financial Turnaround Heather Lynn Weber

NJ HFMA Celebrates Our 2013-2014 Award Recipients

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12 Focus

Data Breaches Highlight Value of Medical Data

by Alex Wozniak

A data breach is the actual release or disclosure of infor-mation to an unauthorized individual/entity which may cause the affected person or company inconvenience or harm. The recent data breaches making headlines, at Target and Home Depot, resulted in the unintentional disclosure of their Cus-tomer’s financial data. Unfortunately, data breaches are not limited to credit card data and other financial information. Even more valuable than the few dollars credit card numbers sell for on the black market, are health care records.1 Health care records frequently include Social Security numbers, desir-able information for stealing someone’s identity.2 New threats to the security of records in the United States healthcare system emphasize the value and demand of patient data.

A 2014 study by the Ponemon Institute indicates that criminal attacks against healthcare systems have risen 100 percent since the study was first conducted in 2010. High-lighted by recent attacks against Community Health Systems and the Healthcare.gov website, the potential cost of data breaches on the healthcare industry could be as much as $5.6 billion annually.3

Community Health Systems is a publically traded company that runs 206 hospitals in 29 states. According to a regulatory filing by the company in August, personal information for approximately 4.5 million patients was stolen by hackers.4 Between April and June, Mandiant, a cybersecurity firm hired by Community Health Systems, believes Chinese hackers bypassed the company’s security systems to steal personal data of patients. The stolen information did not include credit card numbers or medical information, but names, addresses, telephone and social security numbers.5 As required by law, Community Health Systems will notify those patients whose information was stolen and the company will also be offering identity theft protection services to those individuals.

Another, and even more concerning breach occurred on the Healthcare.gov website. According to a statement released by a unit of the Department of Health and Human Services, a portion of the website was breached when hackers uploaded malicious software on a test server.6 The server did not contain personal

information and no data was transferred outside the agency, as the server was not meant to be connected to the Internet. While no data was taken in the breach, it is a valuable reminder that this website contains valu-able information and will be a high value target for hackers.

A variety of factors have lead to the increased exposure of healthcare clients. A majority of healthcare organizations see the implementation of the Affordable Care Act as a contributing factor for this increased exposure.7 While medical providers continue to store patient’s medical information on paper records, government incentives are encouraging a transition of medical records to digital format. Called Electronic Health Records, the hope is that digital records will improve healthcare quality and efficiency, by allowing users to access records from different locations.8 However, this transition also increases privacy risks. A heavy dependency on outsourced service providers mean health information is shared amongst a large number of third parties. And many healthcare organizations are not confident that their business associates would be able to detect and notify the organization if there were a data breach.9

The other factors contributing to the security risk are employee negligence and BYOD usage. As with any industry and business, the human element represents a weakness in even the most secure cyber defenses. A Ponemon study revealed that 75% of organizations say employee negligence is their biggest worry.10 Despite the risk, organizations allow their employees to use their own mobile devices, such as smart phones and tablets, to access their organization’s networks. These unsecured mobile devices allow yet another point of entry into healthcare systems and represent an often unintentional security risk.

Despite these security risks, there are many industry best practices that healthcare organizations can adopt to increase breach preparedness. This begins by having a breach response plan in place before an event occurs. An organization would benefit from conducting breach response exercises and pre- arranging breach response services with a security firm.

Alex Wozniak


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Healthcare organizations should also monitor event logs and secure remote access settings to be more aware of any outside data breaches. The most important thing an organization can do to prevent disclosure of protected information is to encrypt their data. That way, even if there is unauthorized access to the data, it is encoded and unreadable.

In our experience, the large data breaches reported by retailers like Target or Home Depot have had a limited impact on the broad spectrum of the market. Certainly, carriers will want to evaluate their larger accounts, which might be more susceptible to a mega breach due to their size. However, companies of this size already have large self-insured retentions and dedicated Risk Management departments, so the best way for the carrier to limit their exposure would be to restrict the capacity limits offered. For instance, instead of providing the insured $15 Million limits, the carrier may want to only provide half of that amount and ask the insured to find excess coverage elsewhere.

Another noteworthy issue, highlighted in the media by the celebrity exposé scandal, is the increased use of the Cloud. From what we have seen, the use of cloud based services to store data and run applications have only had a limited impact on the market. While insurance coverage is an important issue because cloud providers generally accept very limited liability, some cyber insurance policies are written with language broad enough to cover cloud computing risks. However, as the in-sured is still responsible for the data, the insurer will want ad-ditional information about any cloud based services used. This has resulted in supplemental applications being developed and additional questions being asked by underwriters to help them understand the insured’s exposure.

As these and other breaches continue to occur, so will un-derwriting continue to adapt based on the claims reported. While the underwriting appetite has not changed, there is no one size fits all approach to this coverage and every risk will be viewed differently by every carrier. In our experience, carriers are still competing to write coverage for the best risks. By this we mean those risks which can not only demonstrate an ef-fective system of loss prevention, but also Risk Management policies which are followed and enforced by the insured. These accounts should also possess first rate security systems and up-to-date anti-virus protections.

Like every organization, the U.S. Healthcare system is strug-gling to adapt in the modern world. Technological advance-ments offer opportunities for companies to lower costs and im-prove quality & efficiency. However, these advancements also increase privacy risks. The implementation of legislation has forced the consolidation of digital records and provides targets for hackers. As evident by recent breaches, network attacks on healthcare systems are becoming more frequent and are affect-

ing a record number of individuals. While their focus is on healthcare and not security, the healthcare industry needs to be aware of the rising threat of cybercrime.

About the authorAlex Wozniak is an Executive Risk Consultant with CBIZ Insur-ance Services, Inc. He focuses on the development and implementa-tion of cyber liability, directors & officers, and employment practic-es liability insurance programs for clients in all industry sectors. He is a graduate of Loyola University Maryland. Alex can be reached at [email protected].

Bibliography“Fact Sheet 8d: Protecting Health Information: the HIPAA Se-

curity and Breach Notification Rules.” Protecting Health In-formation: the HIPAA Security and Breach Notification Rules. N.p., n.d. Web. 25 Sept. 2014. <https://www.privacyrights.org/content/protecting-health-information-hipaa-security-and-breach-notification-rules>.

Meyers, Jessica. “Health care industry ill-prepared for vicious cyberthreats - The Boston Globe.” BostonGlobe.com. N.p., 6 Sept. 2014. Web. 24 Sept. 2014. <http://www.bostonglobe.com/news/nation/2014/09/05/health-care-industry-ill-pre-pared-for-vicious-cyberthreats/ZdvDGaipJi7VSN0TogezkL/story.

Millman, Jason. “Health care data breaches have hit 30M pa-tients and counting.” Washington Post. The Washington Post, 19 Aug. 2014. Web. 24 Sept. 2014. <http://www.washing-tonpost.com/blogs/wonkblog/wp/2014/08/19/health-care-data-breaches-have-hit-30m-patients-and-counting/>.

Peterson, Andrea, and Jason Millman. “HealthCare.gov server hacked. But HHS says no consumer information taken..” Washington Post. The Washington Post, 4 Sept. 2014. Web. 25 Sept. 2014. <http://www.washingtonpost.com/blogs/the-switch/wp/2014/09/04/healthcare-gov-server-hacked-but-hhs-says-no-consumer-information-taken/>.

Ponemon Institute. Fourth Annual Benchmark Study on Patient Privacy and Data Security. N.p., n.d. Web. 25 Sept. 2014. <http://www.ponemon.org/blog/fourth-annual-bench-mark-study-on-patient-privacy-and-data-security>.

Sullivan, Gail. “Chinese hackers may have stolen your medical records.” The Washington Post. N.p., 19 Sept. 2014. Web. 24 Sept. 2014. <http://www.washingtonpost.com/news/morn ing-mix/wp/2014/08/19/chinese-hackers-may-have- stolen-your-medical-records/?utm_campaign=KHN:+ First+Edition&utm_source=hs_email&utm_medium= email&utm_content=13838254&_hsenc=p2ANqtz-_s F0EtBvNdGGylzphXEjs8rxztJ_jTiMV3oXoz6CjpOJg-g1FL81Jio2sA1eliH_et3aKQeiPcR1-fBaDf6XQe951o0RM-TY14dV-qWWc0RdBJLBOU4&_hsmi=13838254>.

continued on page 14


14 Focus

Footnotes1Meyers, Jessica. “Health care industry ill-prepared for vicious cyberthreats - The Boston Globe.” BostonGlobe.com. N.p., 6 Sept. 2014. Web. 24 Sept. 2014. <http://www.bostonglobe.com/news/nation/2014/09/05/health-care-industry-ill- prepared-for-vicious-cyberthreats/ZdvDGaipJi7VSN0Togez kL/story.2Millman, Jason. “Health care data breaches have hit 30M patients and counting.” Washington Post. The Washington Post, 19 Aug. 2014. Web. 24 Sept. 2014. <http://www.wash ingtonpost.com/blogs/wonkblog/wp/2014/08/19/healthcare-data-breaches-have-hit-30m-patients-and-counting/>.3Ponemon Institute. Fourth Annual Benchmark Study on Patient Privacy and Data Security. N.p., n.d. Web. 25 Sept. 2014. <http://www.ponemon.org/blog/fourth-annual-bench-mark-study-on-patient-privacy-and-data-security>.4Millman, “Health care data breaches have hit 30M patients and counting.”5Sullivan, Gail. “Chinese hackers may have stolen your medi-cal records.” The Washington Post. N.p., 19 Sept. 2014. Web. 24 Sept. 2014. <http://www.washingtonpost.com/news/morn

ing-mix/wp/2014/08/19/chinese-hackers-may-have-stolen-your-medical-records.6Peterson, Andrea, and Jason Millman. “HealthCare.gov server hacked. But HHS says no consumer information taken..” Washington Post. The Washington Post, 4 Sept. 2014. Web. 25 Sept. 2014. <http://www.washingtonpost.com/blogs/the switch/wp/2014/09/04/healthcare-gov-server-hacked-but hhs-says-no-consumer-information-taken/>.7Ponemon Institute, p.3.8“Fact Sheet 8d: Protecting Health Information: the HIPAA Security and Breach Notification Rules.” Protecting Health In-formation: the HIPAA Security and Breach Notification Rules. N.p., n.d. Web. 25 Sept. 2014. <https://www.privacyrights.org/content/protecting-health-information-hipaa-security-and-breach-notification-rules>.9Ponemon Institute, p. 3-410Ponemon Institute, p. 13


•Certification Corner•

I hope everyone had a great Thanksgiving holiday. Since the last issue, I have some great news to report. The certification study group that we participated in with the New York chapters was a huge success. We had 17 people from New Jersey participate. The sessions ran every Monday night for two hours via

GoToMeeting. Instructors from the NY chapters led the sessions and participants were able to ask questions during the presentations. If someone was not able to attend, the sessions were recorded so that they could be accessed later. Participants’ evaluations indicated that most thought the sessions were extremely valuable.

Since the ending of the session, Alan King from Princeton Medical Center from our Chapter, took and passed the exam! Congratulation, Alan!

We are looking into other programs to add to the Certification calendar in the upcoming months. There may be a joint chapter study group for the Revenue Cycle certification. I will keep you posted.

We are looking forward to more members of the Chapter sitting for the exam. As your Certification Chair, I am available to assist members in any way I am able. Please don’t hesitate to contact me if you have any questions.

Enjoy your holiday season!

Rita Romeu, Certification [email protected]


16 Focus

Once an Overpayment,Forever an “Obligation”The ACA’s 60-Day Rule Makes Murky Business of “Identifying” Overpayments

by Leonardo M. Tamburello, Esq.Leonardo M. Tamburello

The Affordable Care Act (“ACA”) includes an often over-looked provision that severely punishes anyone who, for sixty (60) days or more, knowingly fails to return Medicare or Med-icaid overpayments that have been “identified” as such. Failure to do so transforms the overpayment into an “obligation” under the federal False Claims Act (FCA). The statute does not define what it means by “identified” overpayment, nor has there been any definitive regulatory guidance on this point. Thus, some four years after the ACA’s enactment, it is still not known what it meant by the “identification” of an overpayment in this context.

Despite this, the federal government and State of New York have both recently intervened in a federal FCA action alleging that although a hospital eventually repaid overpayments resulting from a third-party’s coding error, its failure to refund the overpayments with the alacrity required by the ACA’s so-called “60-day Rule” makes it potentially subject to FCA penalties and sanctions. This case should be followed closely to see how the court grapples with providers’ obligations to “identify” overpayments in this context.

1. The 60-day Rule: An ACA Trap for the Unwary.Since 2010, the ACA has required the reporting and return

any Medicaid or Medicare overpayments within sixty (60) days of their “identification.” 1 An “overpayment” is defined as the receipt or retention of any Medicaid or Medicare funds, by a Medicaid or Medicare provider or supplier, Medicare MCO or Medicare Part D prescription drug plan sponsor, “which the person, after applicable reconciliation, was not entitled.”2 Such overpayments must be returned within sixty (60) days from the date on which they are “identified,” or the date that the corresponding cost report was due, whichever is later.3 Proper return of an overpayment is made by: (1) returning it to the federal government, State Medicaid program, intermediary, carrier, or contractor, as appropriate; and (2) notifying the party to which the overpayment is returned the reason for the overpayment, in writing.4

A “knowing” failure to return an overpayment within the sixty days automatically converts it into an “obligation” that is actionable under the FCA.5 Violations of the FCA are punishable by penalties that include: a fine between $5,000 and $10,000 per claim, treble damages, and/or exclusion from federally funded health programs if the offender knowingly conceals or knowingly and improperly avoids or decreases an “obligation” to pay money to the federal government.6 These penalties supplement Medicaid and Medicare’s ability to “offset,” or “recoup,” overpayments by reducing present or future payments and applying the withholding to the indebtedness.7

Although this statute contains some basic definitions, there remain troubling uncertainties concerning what it means for a provider to have “identified” an overpayment. This lack of clarity coupled with the potentially severe penalties under the FCA requires potential overpayments to be investigated and handled in an adroit and expeditious manner.

In February 2012, CMS issued proposed regulations addressing, inter alia, the “identification” of overpayments. Unfortunately, these proposed regulations were never finalized or enacted. 8 Thus, neither the statute nor agency regulations have provided any formal guidance as to what it means to “identify” an overpayment, even though this is the critical inquiry for determining when the 60-day Rule is triggered.

2. Kane: A First Look at the 60 Day Rule in ActionAlthough the 60-day Rule has been in effect for over four

years, no government agency had invoked it against a provider until June 26, 2014 when U.S. Department of Justice (DOJ) and the New York State Attorney General’s office (NYAG) intervened in Kane ex rel. United States v. Continuum Health Partners, Inc., et al., a wrongful termination and FCA matter in the Southern District of New York.9

Kane was the Technical Director, Revenue Cycle Oper- ations, Hospital Systems & Operations at Continuum Health (Continuum) from November 4, 2004 until February 8,


Focus 17

2011.10 In or around September 2010, as a result of a New York State investigation into Medicaid claims of four Continuum patients, Kane discovered that from 2007 to November 2010, an erroneous remittance code (“CAS*CO*2*$$$$.$$”) was used by Continuum that resulted in the improper billing of New York Medicaid as a secondary payer.11 The use of this remittance code was the result of a “coding error” by Healthfirst, the MCO which contracted with the Continuum providers for services to New York Medicaid managed care enrollees.12

Kane alleges that in October 2010, he brought the coding error and fact that Continuum had received overpayments to his supervisors and suggested that Continuum stop its automatic processing of Healthfirst’s electronic remittance and instead revert to manual posting of payments, but his request was denied.13 A few months later, in December 2010, Healthfirst corrected the coding error.14 Notwithstanding this, Kane alleges that Continuum knew of the coding error and resulting overpayments, but took no action to report or return them.15

In February 2011, Kane alleges that his employment was terminated at Continuum in retaliation for his requests to switch to manual billing until the coding error was resolved and to investigate and refund the overpayments that had occurred.16 He filed suit shortly thereafter, but it remained under seal while the DOJ and NYAG investigated the allegations. On June 26, 2014, both the DOJ and State of New York have intervened, asserting their own FCA claims based solely on Kane’s allegations that repayment did not occur within the 60-day timeframe required by the ACA and despite Continuum’s repayment of all amounts in dispute.17

Initially, Kane alleged that the same or similar types of overpayments also occurred at over approximately seventy other hospitals in New York and twenty in New Jersey, but those allegations were voluntarily dismissed without prejudice very early in the case.18

Kane is the first case brought which directly implicates the ACA’s 60-day Rule and bears close monitoring for all providers, not just those directly involved.

3. Paramount Issue in Kane, and for All Medicaid and Medicare Providers: When Were the Alleged Overpayments “Identified”?

All providers should watch Kane carefully to see how the court deals with some unanswered questions about the 60-day Rule, foremost amount them being: When did each hospital identify the overpayments in question?

Since the 60-day Rule was enacted, there has been an ongoing industry concern about what it means to “identify” an overpayment, mostly because the statute does not define this fundamental term. In 2012, CMS proposed regulations that attempted to answer this question, stating that an overpayment

is “identified” when a Medicare or Medicaid provider or supplier “has actual knowledge of the existence of the over-payment or acts in reckless disregard or deliberate indifference of the overpayment.”19 In addition, CMS has commented that a duty to investigate is triggered when a provider “receives information concerning a potential overpayment that creates an obligation to make a reasonable inquiry to determine whether an overpayment exists.”20 Failure to do so “with all deliberate speed” may result in a determination that the provider knowingly retained an overpayment as a result of reckless disregard or deliberate ignorance of whether or not it received such an overpayment.”21

Apropos of Kane, the proposed regulations examine improperly retained overpayments that include the situation where a provider or supplier “reviews billing or payment records and learns that it incorrectly coded certain services, resulting in increased reimbursement….[and where a] provider of services or supplier performs an internal audit and discovers that overpayments exist.”22 Additional examples of overpayments found in the proposed regulations include providers who are “informed by a government agency of an audit that discovered a potential overpayment, and… fail[] to make a reasonable inquiry.”23 In CMS’s view, “[w]hen government agency informs a provider or supplier of a potential overpayment, the provider or supplier has an obligation to accept the finding or make a reasonable inquiry. If the provider’s or supplier’s inquiry verifies the audit results, then it has identified an overpayment and, assuming there is no applicable cost report, has 60 days to report and return the overpayment.”24

These proposed regulations were promulgated with respect to Medicare (but not Medicaid) and accompanied by a statement from CMS that “[o]ther stakeholders, including, without limitation… Medicaid MCOs will be addressed at a later date.”25 Despite this, and although these regulations were never enacted, CMS nevertheless cautioned that the enforcement of the 60-day Rule would not be delayed by the lack of regulatory guidance, saying: “all stakeholders… even without a final regulation… are subject to the statutory requirements… [requiring the return of “identified” overpayments within 60 days] and could face potential False Claims Act liability, Civil Monetary Penalties Law liability, and exclusion from Federal health care programs for failure to report and return an overpayment.”26

Based on CMS’s own comments and illustrated by Kane, the lack of regulatory authority is not an invitation to institutional indifference. Medicare and Medicaid pro-viders that have “actual knowledge” of overpayments, in addition to those who fail to make a “reasonable inquiry” with “all deliberate speed” after receiving information concerning a potential overpayment, are potentially liable under the FCA and its state-level equivalents. Policies and continued on page 18


18 Focus

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procedures should be created and followed to insure that: first, if overpayments are suspected or suggested, they are promptly investigated; and second, if they are identified, they are properly returned and reported as required by the ACA’s 60-day Rule.

Identification of overpayments is one of the “major op-erational requirements” of the Medicaid Integrity Plan.27 Special consideration should therefore be given to this issue

in the context of RAC audits, as RAC auditors have been specifically tasked to identify and recover potential overpayments, and do so on a contingent-fee basis.28 To this end, RACs employ “overpayment algorithms” “to identify claims with possible overpayments,” which are also used to iden-tify providers suspected of high overpayment.29 Moreover, if an overpayment is identified during a RAC audit, it must classify it as an improper payment (which includes overpay-

ments and underpayments), a data pro-cessing error, a medical review error, fraud, or abuse.30

Although it is the first case where the ACA’s 60-day Rule has been invoked, Kane is almost assuredly not the last. In addition to providing a powerful tool to government regulators, the ACA’s 60-day Rule also strongly incentivizes qui tam Plaintiffs to bring potentially costly lawsuits in situations where overpayments are not promptly investigated and reconciled. Policies and procedures, if they have not already been updated, should be revised along with employee training practices to reflect the changes ushered in by the 60-day Rule. Compliance programs should designate individual responsibility for the prompt investigation of possible overpayments from non-commercial payers and insure that any overpayments that are “identified” are repaid and explained with 60 days.

About the authorLen Tamburello is Of Counsel in the Healthcare Practice Group at McElroy, Deutsch, Mulvaney & Carpenter, LLP in Morristown. He concentrates his law practice on the representation of healthcare providers in a variety of litigation and dispute resolution contexts including medical malpractice defense, compliance, audits, fraud and abuse, and HIPAA/HITECH privacy and information security issues.

Endnotes142 U.S.C. § 1320a-7a(d).242 U.S.C. § 1320a-7k(d)(4)(B) and –(C).3Id. at § 1320a-7k(d)(2)




Focus 19

Joseph DudekHBCSVice President, Sales & Marketing(302) [email protected]

Cheryl Marks YoungEaster Seals New JerseyChief Financial Officer(732) [email protected]

Diane M. ZucchinoAtlantic Health SystemCDM Coordinator(973) [email protected]

Jennifer Lynn GilloolyHealth Republic Insurance New JerseyAdvocate(973) [email protected]

Shannon E. Roy, CRCRRevenue GuardCollections [email protected]

Niku TrivediChenoa Information Services, Inc./Chenoa HealthEVP(732) [email protected]

William JacksonFirst Credit Services Inc.Vice President(800) 606-7066 x2019 [email protected]

Lynn M. RileyCape Regional Medical CenterAR Coordinator(609) [email protected]

Karolina SzastKaromed, LLCPresident(201) [email protected]

Joyce MathesonDeborah Heart & Lung CenterDirector Compliance(609) 893-1200 [email protected]

Chris TomickiProfit Tek LLCChief Executive Officer(201) [email protected]

Kumar Alok UpadhyayHCL America Inc.Head, Healthcare Business Solutions(630) [email protected]

Luv DuaOpera SolutionsDirector, Healthcare Solutions(646) [email protected]

Kim BakerFox RehabilitationCompliance Officer & Director of Program Integrity(877) [email protected]

Ritin KhangarotOpera Solutions(646) [email protected]

Jean RomanoSutherland Global ServicesVP Provider Services(631) [email protected]

Cort SteelKPMG LLPMarketing Director(201) [email protected]

Eileen T. CrilleyHoly Name Medical CenterDirector Call Center Operations(201) [email protected]

Devendra SahariaAGS Health Inc.(570) [email protected]

Evelyn Lara(973) [email protected]

Thomas M. Walsh, Jr.University Hospital Of New JerseyCase Manager-Compliance Investigator(973) [email protected]

Adriane Cooper-DulaRutgers University-NJMSManager Finance(973) [email protected]

Brielle M. BoganBayada Home Health CareAssociate(800) 220-0133

Joseph M. DiBellaConner Strong BuckelewManaging Director(856) [email protected]

Cheryl PickellJersey Shore University Medical CenterAccess Services Manager(732) [email protected]

Stefanie SharpCarePoint Health(917) 363-9798

Maureen R. DunnBarnabas HealthIT&S Director Revenue Cycle Systems(732) [email protected]

Elizabeth A. Russ, PhDExigo ConsultantsManaging Partners(609) [email protected]

Karen FaheyCooper University HospitalDirector HIM(856) [email protected]

David HabibHoly Name Medical CenterAVP of Finance(201) [email protected]

Kevin LarkinMckesson Enterprise IntelligenceBusiness Advisor(609) [email protected]

Barry J. Rings, Jr.Med-metrixImplementation Coordinator(201) [email protected]

Edward C. ZeruldCooper University HealthVice President(856) [email protected]

Lori PietropolaVirtuaDirector of Patient Access(856) [email protected]

Ramalingam Ganesh(609) [email protected] H. KadenFischer Barr & Wissinger LLCPrincipal(973) [email protected]

Anna MartzPATHS, LLCDirector - Client Services(856) [email protected]

David HaierUniversity Physician Associates of NJ, Inc.Chief Operating Officer(973) [email protected]

Michael AlbaneseTD BankVice President(732) [email protected]

Amanda C. WatterHuron Consulting GroupManager(732) 991-3282 [email protected]

John CapraPractical Design Services, LLCPrincipal Owner(973) [email protected]

Kathleen DoughertyPenn MedicineManaging Director(215) [email protected]

Sihui ZhouDeloitte & ToucheERS Consultant(973) [email protected]

Ryan D. SchaferT-system Revcycle+Sales(908) [email protected]

Ashleigh M. GoetzThe Children’s Hospital of PhiladelphiaBusiness Analyst(267) [email protected]

Frank M. RodriguezCarepoint Health Medical GroupManger of Managecare Credentialing and Managecare Contracts(201) [email protected]

Johnny RodriguezMt. Sinai Beth IsraelCorporate Billing Supervisor(212) [email protected]

Bradley G. Gingerich, CRCREnsemble Health PartnersVice President(440) [email protected]

Jose L. OrtizThe Gastro Surgi Center of NJ LLCBilling Director(908) [email protected]

Mary RewinskiInspira Health Network Medical Group, PCExecutive Director(856) [email protected]

Lisa M. WertheimerAria HealthDirector, Physician Services(215) 807-8385 [email protected]

New Members



20 Focus

4Id. at § 1320a-7k(d)(1).5Id. at § 1320a-7k(d)(3).6See 31 U.S.C. § 3729 (FCA penalties) and 42 U.S.C. § 1320a-7 (exclusion). 7See generally, 42 C.F.R. 405.370.877 Fed. Reg. 32, 9179-9187 (Feb. 16, 2012).9Kane ex rel. United States v. Continuum Health Partners, Inc., et al., Civil Action No. 11-2325(ER) (S.D.N.Y.) (Complaint-in-Intervention filed on behalf of the United States), available at http://www.justice.gov/usao/nys/pressreleases/June14/Con tinuumHealthPartnersincLawsuotPR/Continuum%20HealthPartners,%20Inc.,%20et%20al.%20Complaint%20in%20Intervention.pdf, and id. (Complaint-in-Intervention filed on behalf of New York Attorney General).10Kane ex rel. United States v. Continuum Health Partners, Inc., et al., Civil Action No. 11-2325(ER) (S.D.N.Y.) Relator’s Amended Complaint at ¶ 6.11Id. at ¶ 5.12Kane, supra, New York Attorney General’s Complaint-in-Intervention at ¶ 21, 31.13Kane, supra, Relator’s Amended Complaint at ¶ 40.14 Id. at ¶ 42.15Id. at ¶ 45.16Id. at ¶ 52-63.

17Kane, supra, Complaint-in-Intervention filed on behalf of the United States) and New York Attorney General’s Complaint-in-Intervention.18Kane, supra, Relator’s Amended Complaint at ¶ 16-17, 79-87.1977 Fed. Reg. 32, supra, at 9187 (proposed 42 C.F.R. § 401.305(a)(2)).20Id. at 9182.21Ibid.2277 Fed. Reg. 32 at 9182.23Ibid.24Ibid.25 Id. at 9180.26 Id. at 9180-81.27CMS Manual Pub. 100-15 Medicaid Program Integrity Manual § 4005 (Sept. 23, 2011). Available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS1238527.html2842 U.S.C. § 1396a(a)(42).29CMS Manual Pub. 100-15 Medicaid Program Integrity Manual §§ 2005 (Data Analysis and Information Gathering), 9000 (Identifying Potential Audit Subjects), and 9015.5 (Information Technology Infrastructure).30Id. at § 1035.


Jeanmarie TenutoHealthcare Technical SolutionsChief Executive Officer(866) [email protected]

Lauren BianchiCooper University HospitalSenior Financial Analyst(856) [email protected]

Jerry FitzgeraldChg MeridianSenior Account Manager(908) [email protected]

Mia MorseRutgers UniversityBudget Analyst(973) [email protected]

Lisa ShandsVirtuaIT Audit Manager - Internal Audit(856) [email protected]

Ryan CharzewskiPricewaterhouseCoopers LLPManager(973) [email protected]

Jatin MotiwalAtlantiCare Physician GroupVice President(609) [email protected]

Stephen F. PalatucciMemorial Sloan Kettering Cancer CenterBusiness Analyst(111) [email protected]

Courtney WalshBayada Home Health CareBilling and Collections Associate(856) [email protected]

Kelly CascioStrive Physical TherapyDirector of Admin [email protected]

Surya SontiAmvest Financial Group IncInvestment Banker(302) [email protected]

Barbara QuackenbosEpstein & Quackenbos PCAttorney(973) [email protected]

Steve CarterSolomonEdwards GroupManager(215) [email protected]

Robert E. Kane IIIBayada Home Health CareDirector(973) [email protected]

John PhillipsDeloitte LLPDirector, Business Valuation(973) [email protected]

Robert ScharffBayada Home Health CareManager(856) [email protected]

Anthony Flammia(973) [email protected]

Shavane T. ThompsonChildren’s Specialized HospitalSr. Patient Access Liaison(908) [email protected]

Simone Allen-SheffieldChildrens Specialized HospitalSupervisor Insurance Verification and Authorization(732) [email protected]

Chassidy Woods-NesmithRutgers UniversityEthics Training Officer(732) [email protected]

Robert EsHaqEmergency Medical AssociatesDirector, Financial Reporting and Accounting(973) [email protected]

James P. McDonaldVice President(973) [email protected]

Judy KellyChildrens Hospital of Philadelphia(267) [email protected]



Focus 21

•Who’s Who in NJ Chapter Committees•

2014-2015 Chapter Committees and Scheduled Meeting Dates*NOTE: Committees have use of the NJ HFMA Conference Call line.

If the committee uses the conference call line, their respective attendee codes are listed with the meeting date.

PLEASE NOTE THAT THIS IS A PRELIMINARY LIST - CONFIRM MEETINGS WTH COMMITTEE CHAIRS BEFORE ATTENDING.

CHAIRMAN/EMAIL/ CO-CHAIR/EMAIL/ SCHEDULED MEETING MEETING BOARDCOMMITTEE PHONE PHONE DATES*/TIME LOCATION LIASON Lisa Hartman Dara Quinn/Deb Carlino First Thursday of the Month Meeting in person at Deloitte & Touche, Stacey BigosCARE (Compliance, [email protected] [email protected] / [email protected] 9:00 AM Princeton, NJ for Oct., Jan., April and July [email protected], Risk, & Ethics) (908) 507-7065 (201) 388-0637 / (973) 972-3260 Balance are calls. Please call to confirm (609) 275-4017

Elizabeth Litten Al Rottkamp First Thursday of each month Fox Rothschild offices Brian HerdmanCommunications [email protected] [email protected] 9:30 AM 997 Lenox Dr Bldg 3 [email protected] (609) 896-3600 (609) 790-3562 Lawrenceville, NJ

Mike McKeever Mary Cronin & Stacey Bigos First Friday of each month Scott MarianiEducation [email protected] [email protected] / 10:00 AM Conference Calls [email protected] (732) 745-8600 x5089 [email protected] (973) 898-9494 x420 (732) 839-1217 / (609) 275-4017

Certification Rita Romeu To Be Determined Mike McKeever(Sub-committee [email protected] 10:00 AM Conference Calls [email protected] Education) (973) 418-6071 (732) 745-8600 x5089

FACT (Finance, Karen Henderson Monika Finnegan Second Wednesday of each Month Megan ByrneAccounting, Capital [email protected] [email protected] 8:00 AM Conference Calls [email protected]& Taxes) (973) 532-8879 (609) 383-2115 (732) 516-4696

Jennifer Vanegas Mike McKeever Fourth Thursday of each Month Tracy Davison-DiCantoInstitute 2014 [email protected] [email protected] 8:00 AM Conference Calls [email protected] (585) 643-3377 (732) 745-8600 x5089 (609) 529-9461

Belinda Doyle Puglisi John Brault 9/8/14 (1 hr. conf. call only) Children's Specialized Kevin JoyceManaged Care [email protected] [email protected] 9/12/14*, 10/13/14, 2:00 PM (Two Locations) [email protected] (908) 301-5458 (973) 244-3536 11/10/14, 12/17/14 *NJHA (732) 562-7823

Jennifer Barr Maria Facciponti Call for meeting arrangements Locations alternate Stella VisaggioMembership Services/ [email protected] [email protected] by month - [email protected] (201) 821-8932 please contact the chairs (908) 850-6928

Dara Derrick Maria Lopes-Tyburczy 11/10/14, 12/17/14 (with Managed Care*) CBIZ KA Consulting offices Mary TaylorPatient Access Services [email protected] [email protected] 1/8/15, 3/12/15, 5/14/15 9:30 AM in East Windsor, NJ [email protected] (908) 850-6870 *at Children’s Specialized, 2:00 pm

Steven Stadtmauer Cynthia Kaufhold Second Friday of each Month Josette PortalatinPatient Financial [email protected] [email protected] 10:00 AM New Jersey Hospital Association [email protected] (973) 778-1771 Ext. 146 (201) 833-7012 Board Room (201) 291-6017

Jennifer Shimek Deborah Carlino/Tony Panico Second Thursday of every other month Conference Calls Steven BilskyPhysician Practice [email protected] [email protected] / [email protected] (Sept. 11, Nov. 13, Jan. 8, Sept. & Jan. meetings will also be in person [email protected] Form (732) 516-4676 (973) 972-3260 / (973) 898-9494 March 12, May 14) 9:00 AM Room TBD (303) 672-9896

Kathryn Gibbons Peter Demos Third Tuesday of each Month Monmouth Shores Corp. Park Scott BeslerRegulatory & [email protected] [email protected] 9:00 AM Meridian Conf. Room 1C [email protected] 1350 Campus Pkwy, Neptune

Christine Putterman Helene O'Donnell First Wednesday of each Month Rosemary NuzzoRevenue Integrity [email protected] [email protected] 9:00 AM Princeton HealthCare System [email protected] (215) 707-5917 (215) 882-1670 (609) 383-2114

Lew BivonaCPE Designation [email protected]


22 Focus

The Nicholson Foundation Continues to Partner with and Support the New Jersey Health Care Quality Institute and Medicaid ACO Demonstration Project

by Dave Knowlton & Joan Randell

The Nicholson Foundation recognized early on that if New Jersey wanted to improve health care in its underserved communities, it must change the way health care is provided and paid for. Unfortunately, with budget shortfalls and other pressures, there was no state funding for a new visionary model called the Medicaid Accountable Care Organization (ACO). The Nicholson Foundation stepped up to fund both nascent community coalitions that wanted to create Medicaid ACOs and the Quality Institute to serve as a convener and learning network for the coalitions.

Because of The Nicholson Foundation’s support and commitment to the vision of the Medicaid ACO and the Quality Institute’s ability to foster and support these coalitions, this summer seven communities applied to become Medicaid ACOs. The level of interest from as far north as Paterson and far south as Cumberland is a testament to the energy and passion behind the Medicaid ACO model. Given recent Medicare ACO results, the path will be difficult and lengthy but it is a journey that must start somewhere and start now. In New Jersey we have The Nicholson Foundation to thank for starting us down the path. Now the hard work begins.

Recently, I reached out to Joan Randell, Chief Operating Officer of The Nicholson Foundation, and asked her to share her thoughts about the Medicaid ACO applicants and the Quality Institute’s learning network for them.

Here’s what Joan had to say:

Health care is a critical entry point for addressing the complex web of problems that accompany poverty and social disadvantage. The Nicholson Foundation believes that we need to improve the access, quality and affordability of health care to improve the lives of New Jersey’s most vulnerable citizens.

We were initially inspired by the innovative work of Dr. Jeffrey Brenner, who used data to identify and locate the highest users of hospital services at Camden’s three hospitals. He found that many of these patients could have avoided costly inpatient

by Dave Knowlton


Focus 23

and emergency department services if timely primary care was readily available—and if this care also was coordinated with the social and economic support needed by these patients.

Jeff then brought together Camden’s competing hospi-tals, primary care providers and community organizations to work together to improve care for patients. He also creat-ed multi-disciplinary care management teams to work with patients who had the most hospital visits. He sought out these patients and coordinated their overall care.

The effort to bring all of Camden’s medical providers and community organizations together and encourage them to work collaboratively to improve the health of patients was the first example of what a Medicaid ACO could look like in New Jersey. Nicholson saw the potential of this model, and wanted to encourage other communities in New Jersey to create similar collaborations.

So we turned to the New Jersey Health Care Quality Institute, a trusted name in New Jersey health care, to provide a roadmap, and support, for communities that also wanted to transform health care for their underserved residents. We chose the Quality Institute because of their standing and credibility.

We began working four years ago with the Quality Institute to stimulate the creation of Medicaid ACOs. In the first year the goal was to simply share knowledge about ACOs. What are they? How do they work? How can providers and communities start ACOs? How will shared savings provide resources to support and sustain innovations?

Over the next two years, Nicholson jump-started the research and development process for the ACOs by supporting the creation of the Quality Institute’s Affiliated ACOs learning network. The purpose of the organization is to strengthen health care reform efforts in underserved communities by helping Medicaid ACOs take shape, sharing and implementing best practices, and minimizing systemic obstacles to success.

We now are embarking on an exciting time for Medicaid ACOs in New Jersey. This year, the state issued regulations to implement the Medicaid ACO Demonstration Project. The demonstration project’s goal is to improve individual and population health, and to reduce the costs of care through collaboration among providers, payers, community service providers and residents. Ultimately, communities that create these projects will share in the cost savings that are generated and the savings can go to improving their communities.

In August, the state received initial applications from seven communities to be part of the Medicaid ACO

Demonstration Project: Camden, Trenton, Newark, Cumberland County, Gloucester County, New Brunswick and Paterson. Along with the Quality Institute, The Nicholson Foundation wants to help these communities transform the way care is delivered to their poorest residents. As communities embark on this new model, we want to measure the success of their efforts. Are these ACOs reducing unnecessary hospitalizations? Are health outcomes improving? Will there be cost savings? What needs to change along the way?

Hurdles remain and we don’t know the future. But we do know that we must move forward and try innovative strategies like Medicaid ACOs, which have the potential to improve the health and lives of New Jersey’s most vulnerable residents. We are delighted to be a partner with the Quality Institute and the seven Medicaid ACO applicants on this important journey.

To read more commentary from Dave Knowlton, President & CEO of the New Jersey Health Care Quality Institute, please visit www.njhcqi.org and click on Knowlton Knotes.


24 Focus

A.Q.I have to file the Schedule M with the Form 990 this year. To which type of charitable income does this schedule pertain? And how do I properly value these contributions?

Federal Form 990, Schedule M, Noncash Contributions, is used by tax-exempt organizations that are required to report noncash contributions received during the year. If a tax-exempt organiza-tion receives more than $25,000 of noncash contributions or receives contributions of art, historical treasures or qualified con-servation contributions during the year, it is required to com-plete Schedule M when filing the Form 990.

Noncash contributions, also often known as gifts-in-kind (or in-kind donations), are a type of charitable giving in which goods and services are provided to a tax-exempt organization in lieu of a cash donation. Often times, these donated goods and services are items that the organization would have had to purchase had the items not been donated. Examples of in-kind gifts include food, clothing, medicine, and equipment. Prior to determining the value of the donation an organization needs to determine if the item may be used in carrying out their mission. If an organization determines that the items cannot be used or sold, then the organization should treat the transaction as if it did not occur and not account for the donation.

Many tax-exempt organizations, especially foundations, are dependent on the support which is donated to the organization during the year. While cash contributions are typically a large part of the support these organizations receive, gifts-in-kind are also frequently contributed. With the increase in the amount of in-kind gift donations many tax-exempt organizations are re-ceiving, questions regarding the valuation and “worth” of these types of gifts are on the rise.

VALUATION/MEASUREMENT OF GIFTS-IN-KIND Tax-exempt organizations are typically required to use fair mar-

ket value to measure gift-in-kind contributions. Fair value is de-fined in FASB ASC Topic 820 as “the price that would be received to sell an asset or paid to transfer a liability in an orderly transac-tion between market participants at the measurement date.”

In order to determine the fair market value, the organiza-tion must identify the “principal exit market,” which is the mar-

ket in which the organization could sell the asset or transfer the liability. Additionally, the organization must recognize that the donor’s market and the principal exit market of the tax-exempt organization are not the same. Therefore, generally donor provided values are not the same as fair market value.

Lastly, the organization must consider any legal restrictions that may be placed on the gift- in-kind, which will likely im-pact the determination of po-tential market participants and, therefore, would affect fair market valuation. This is imperative as this will allow the organiza-tion to determine if accepting the gift will be advantageous for them.

For income tax purposes, tax-exempt organizations cannot provide a donor with the assigned value of a gift-in-kind. If applicable, a valuation relative to the fair market value of the donated item needs to be prepared by a professional. This is the responsibility of the donor and not the organization. In acknowledging the donation, an organization should include a description of the donated item and may also want to include the practical value or benefit, to the organization.

CONCLUSION Contributions, either cash or noncash, are often large sources

of revenue for tax-exempt organizations. It is important that or-ganizations understand the effects of accepting these gifts. Tax-exempt organizations should have a policy for assessing gifts-in-kind prior to their acceptance of them. It is also important to note that prior to the acceptance of any gifts-in-kind the organi-zation should determine that such item can be used in carrying out their charitable mission.

Schedule M, Noncash Contributions And Gift-In-Kind Valuations

Karen L. Henderson

•Focus on Finance•

By Karen L. Henderson, CPA and Hayley Shulman, CPA

Hayley Shulman


Focus 25

Organizations should also educate their employees regarding acceptance of gifts-in-kind by training them to understand the nature of the items that are received as well the donor’s intent for the gift-in-kind. Having this understanding is critical to cor-rect financial reporting. Lastly, costs versus benefits must be con-sidered. If the cost of obtaining a valuation of a gift-in-kind is greater than the value of receiving the gift in the first place, then perhaps the gift is not worth accepting.

About the AuthorsKaren L. Henderson, CPA, Senior Tax Manager, and Hayley L. Shulman, CPA, Senior Accountant, are both active members of the Healthcare Services Group at WithumSmith+Brown, Certi-fied Public Accountants and Consultants. They can be reached by email at [email protected] or [email protected].

•Focus on...New Jobs in New Jersey•

JOB BANK SUMMARY LISTINGHFMA-NJ’s Publications Committee strives to bring New Jersey Chapter members timely and useful information in a convenient, accessible manner. Thus, this Job Bank Summary listing provides just the key components of each recently-posted position in an easy-to-read format, helping employers reach the most qualified pool of potential candidates, and helping our readers find the best new job opportunities. For more detailed information on any position and the most complete, up-to-date listing, go to HFMA-NJ’s Job Bank Online at www.hfmanj.org.

[Note to employers: please allow five business days for ads to appear on the Web site.]

Job Position and OrganizationSenior Financial Reporting Analyst Capital Health

Partnership Manager AmeriHealth NJ

Provider Performance Manager AmeriHealth NJ

Manager of Managed Care CentraState Healthcare System

Senior Budget / Cost Analyst Children’s Specialized Hospital

Account Rep Atlantic Health System

Coordinator Atlantic Health System

Account Advisor Atlantic Health System

Corporate Controller CarePoint Health – Jersey City, NJ

Director of Finance Monmouth Medical Center, Southern Campus

Vice President, Healthcare Finance & Managed Care HAP c/o Tyler & Company

Director of Revenue Cycle Robert Wood Johnson University Hospital Hamilton


26 Focus

Stabilizing Health IT Expenditures While Maximizing Productivity

by Jennifer Vanegas

Jennifer Vanegas

Hospitals and health care systems rely on up-to-date tech-nology to run their organizations and stay competitive. IT managers invest significant time in planning system acquisi-tions and upgrades to meet regulation requirements and or-ganizational needs. However, they often fail to consider the impact of the acquisition method on the organization.

The Limitations of Purchasing Purchasing IT equipment is essentially a commitment to

long-term use of a particular technology. However, given the rapid evolution of technology, projecting the useful lifespan of IT assets is often difficult at the time of acquisition. Health care organizations that purchase IT equipment often find them-selves saddled with aging and/or obsolete equipment. As these assets approach the end of their useful life, the costs associated with hardware maintenance, operating system upgrades, and internal support escalate. As the IT department struggles to keep systems running with patches and workarounds, down-time and user complaints increase.

Replacing obsolete IT equipment by direct purchase is also a significant expense that typically requires detailed capital ex-penditure documentation and financial rationales. Preferring to avoid a large cash outlay, management may delay approval and implementation of the project. Such delays exacerbate the challenges of maintaining the old equipment. Lost opportu-nity costs also begin to rise as the IT department becomes so burdened with maintaining existing systems that they cannot implement forward-looking projects.

A Better Way to Acquire IT EquipmentLeasing enables organizations to acquire needed equipment

without large cash outlays. Equipment is rented from the leas-ing company with consistent, fixed-rate monthly payments for an appropriate term (often 36 months for technology equip-ment). Most organizations account for the monthly payments as operating expenses.

When the lease reaches maturity, the organization has several disposal options: return the equipment to the leasing company, continue to rent the equipment, or purchase the equipment. If the organization elects to return the equipment, they can often acquire new technology without affecting the monthly operating expense.

As shown in Figure 1, the cash outflows for IT in a purchase scenario experience capital expenditure spikes and creeping maintenance costs. Leasing eliminates these peaks and valleys while ensuring that the organization has leading-edge technol-ogy to support its goals and objectives.

The disciplined refresh strategy of leasing can also improve interdepartmental interactions. Because equipment acquisi-tions have pre-determined time horizons, IT managers can re-liably schedule system upgrades and new application rollouts. The organization no longer perceives IT as unreliable and chronically behind schedule and instead begins to view the IT department as partners in improving productivity.

Furthermore, instead of devoting finite resources to fight-ing for capital appropriations, IT managers can focus on im-proving IT usage and efficiency.



Focus 27

Welcome to the Education Committee

by Michael P. McKeever, CPA, CHC, CHRC

Michael P. McKeeverNow that the 38th Annual Institute is just a memory, one

might think that the Chapter’s Education Committee will be relaxing for a few months before the request for abstracts goes out in anticipation of next year’s Institute. For those of you who are not aware, for the past 2 years the Education Commit-tee has been responsible for establishing the educational agen-da for the Annual Institute, an agenda this past year which included 2 Keynote Speakers, 6 General Sessions, 33 Breakout Sessions and a Panel Discussion. Last winter, in response to the request, the Chapter received 81 abstracts for the Institute, which a dozen members of the Education Committee reviewed and ranked based on content, originality and responsiveness to those published topics identified by the Chapter’s committees and forums. Given the number of abstracts received, this was a monumental task, and I thank those who helped shape this year’s comprehensive and informative agenda.

The strength of the New Jersey Chapter resides in the indi-vidual Forums and Committees that focus time and energy on their specific areas of interest throughout the realm of health-care. As we all know, the full day sessions produced by these focus groups form the backbone of our annual educational agenda. The Education Committee exists to fill in the gaps that exist in our members’ educational needs as well as to explore the possibilities of presenting new topics to the Chapter, often through collaborative efforts with our groups. And of course none of this would happen without the hard work and dedica-tion of the Committee’s Co-Chairs, Mary Cronin and Stacey Bigos, as well as a strong core group of volunteers who are are willing to pitch in.

As this edition of the Garden State Focus is going to press the Education Committee is busy planning a collaborative education session with NJ HIMSS that focuses on topics of interest to both IT and Finance professionals. This has been a regular item on the Chapter’s agenda, and it is a pleasure to work closely with our colleagues from NJ HIMSS in the planning and execution of what has always been an informative day. We are hoping to pick a date in late January or early February for this event. Check the Chapter’s website for additional information on this and other education sessions.

During February we will be presenting the annual Cost Report update. This session focuses on those mandated changes to the Cost Report that are new, as well as those prob-lematic areas that providers struggle with year after year. And although the Regulatory and Reimbursement Committee does an outstanding job presenting Medicare’s annual updates, the Cost Report session provides practitioners a granular view of the mechanics of preparing the annual report to CMS. For those charged with the preparation or review of the Medicare Cost Report this is a must attend session.

Another project currently in the planning stages is our an-nual Women’s Session, which by the way is not for women only! A special thanks to Heather Stanisci for agreeing to Chair this year’s event, which is tentatively scheduled for mid-April. The Women’s Session usually focuses on topics that are relevant to women in healthcare, combining interesting speakers and panel discussions. If you’ve attended in the past, we want this to be the best year yet. If you haven’t attended in the past, seriously consider coming this year, as it’s always a fantastic day.

The Education Committee is also charged by the Chapter with assisting members in achieving certification from HFMA National. Rita Romeu chairs our certification efforts, which has recently hosted a series of webinars presented by a nation-ally known expert on HFMA Certification, and a subsequent study group that is a collaboration with other interested Chap-ters. This group has been meeting via webinar to prepare for the exam. It is an ongoing goal of the NJ Chapter to assist our members in any way possible to achieve certification. If this is a personal goal please let us help you reach it.

Over the past few years another sub- committee, under the leadership of Sandy Gubbine, has been presenting monthly webinars to our members. The vast majority of these presen-tations have been free, thanks to our many partners who are willing to assist us with both the technology and the content. As the Chapter does not have access to a webinar platform, the assistance offered by our various partners has been instrumen-tal in making these monthly webinars a reality. These webinars continued on page 32


28 Focus

The Bottom LineLeasing enables health care organizations to maximize both

their IT operations and their balance sheets. For more infor-mation about how leasing can help your organization, contact First American Healthcare Finance.

About the authorJennifer Vanegas has 14 years of finance experience to help cli-ents acquire clinical equipment and technology to improve patient care. Jennifer serves as the Chair of the NJ HFMA Annual Insti-tute. First American is the exclusively endorsed finance partner of the AHA and is an HFMA Peer Reviewed Service. Jennifer can be reached at [email protected].

First American Healthcare FinanceFirst American Healthcare Finance is an experienced lessor

specializing in the health care industry. As a wholly owned sub-sidiary of City National Bank (NYSE: CYN), First American provides simple, innovative financing solutions at competi-tive rates. First American specializes in combining products and services from multiple vendors and service providers into a single equipment lease. First American has a long-standing reputation for professionalism and exceptional service among health care borrowers throughout the U.S.


We asked….You answered!!Webinars is the number one way NJ HFMA members want to get education!!

The NJ HFMA Education Committee is working on setting up a 2015 “free” webinar calendar for the 3rd Thursday of every month for NJ HFMA

members and colleagues.

If you have an idea or know someone who would like to provide a free webinar to NJ HFMA members and colleagues, just email your idea/summary to:

[email protected]

Webinar summaries should include:1. Brief description of topic2. Presenter Bio3. If you can provide webinar software for registration and presentation.

We are open to providing more than one webinar a month if we find the interest.

To Everyone: Feel free to reach out to us with ideas of webinar topics and how often you would like to see webinar availability by emailing: [email protected]


Focus 29

Utilization of Healthcare Services Special ReportRedefining Care for our Communities

by Jeff Hoffman

Most healthcare leaders would agree that the industry is in the midst of one of the most transformational changes in its history. There is recognition from payors, providers, and government officials that the current system is based on a perverse incentive model that rewards the provision of “sick care” as opposed to “well care.” Tolerance for the current model is rapidly declining. Today, numerous healthcare organizations have started their transformational journeys, and promising models have emerged that are having early successes. While best practices will continue to evolve, the care delivery models and incentive structures that need to be developed for future success are becoming more defined. Networks of providers will be accountable for managing the health of defined populations, and provider reimbursement will be at risk for providing high value care. It is our belief that to have success in this new paradigm, organizations must remove significant amounts of excess utilization and lower the medical cost of their attributed lives. What is not clear is how much utilization will need to be removed and how quickly it must happen. While these two factors will certainly be market dependent, this report explores the expectations of healthcare executives on how healthcare utilization will change in the future and compares their expectations to where we believe healthcare organizations will need to drive utilization levels to be successful in the future.

Methodology An electronic survey was distributed in March 2014 to

executives and board members at hospitals and health systems around the country. The survey asked respondents to predict changes in utilization of various services. In each case, they were asked if, over the next five years, they expected to see an increase or decrease and the magnitude of the change.

123 surveys were completed. Over 80% of respondents were C-level officers, with the remainder consisting of Presidents, Senior VPs, and board members. Responses came from 38 states. There was broad representation from both small and large hospitals as well as respondents representing independent hospitals and hospitals part of health systems.

The survey responses were compared to the differences between Well Managed and Loosely Managed utilization benchmarks for healthcare delivery systems as defined by actuarial consulting firm Milliman, in its Health Cost Guidelines (HCGs). The HCGs are a set of benchmarks for healthcare utilization and cost, based on data from commercial insurance carriers and Medicare. The two sets of benchmarks make up a spectrum that ranges from organizations with limited medical management activities (Loosely Managed) to organizations that perform extensive medical management activities (Well Managed). The Well Managed benchmarks in aggregate represent a theoretically achievable model of care, but are not necessarily being achieved by any organization across all metrics in today’s environment.

Currently, the utilization for most health care delivery systems falls closer on the spectrum to the Loosely Managed benchmarks than the Well Managed benchmarks. The assumption used for our analysis is that health care delivery systems will be moving toward the Well Managed benchmarks over the course of the next five years (although it is our expectations that the majority of healthcare organizations will take longer than five years to achieve Well Managed utilization levels). Therefore, by measuring the gap between the Loosely Managed and Well Managed benchmarks of the HCGs, we can begin to estimate the potential change in utilization as organizations transition over time and compare this to the expectation of the healthcare executives from the survey.

Detailed FindingsInpatient Comparison

When asked how the utilization of all inpatient services, mea-sured by admissions per 1,000 population, would change over the next 5 years, 63% of our survey respondents expected a decrease, 16% expected an increase, and the remaining 21% expected no change. On average, the expected change was a 3% decrease. Among the executives predicting the largest decreases, 5 out of 12 executives specifically cited increased population health manage-ment as a primary contributor to the decline.


Jeff Hoffman


30 Focus

Based on the estimates built using the HCG data, a well-managed population should see a reduction of inpatient admissions per 1,000 population of 30% relative to loosely managed levels (which are already 10% lower than they were 5 years ago). This figure is based on real data observed from plans and providers that have more mature population health management in place. While it is unlikely that care will fully transition to Well Managed levels over the next five years the discrepancy between the survey estimate and these models (along with recent historical trends) suggests that executives are not preparing for demand changes of this scale.

To gain additional insight, we asked similar questions about the utilization of specific inpatient services. Surprisingly, when asked about Cardiovascular, Orthopedic, General Surgery, General Medicine, Oncology, and Neurosciences inpatient services, the average executive expected an increase in utilization for all of these other than General Medicine. Even among those executives who expected overall inpatient services to decrease by at least 5% (40 of the 123), almost two-thirds expected an increase for any particular non-General Medicine service line in the next 5 years. Based on our data-driven models, all of these should expect decreases of 25-35% from a transition to Well Managed population health.

A total of 8 executives referenced the aging population at least once in their responses, with the references spread around the various service areas. We recognize that while changing reimbursement models and population health management should result in decreasing utilization of many services, the steady aging of the US population is expected to counteract the impact somewhat. The percentage of US residents, older than 65, is projected to increase from 14.5% to 16.3% by 2019, which should result in a 4-5% increase in utilization of inpatient days based on current utilization patterns.

Another frequently-cited reason to expect fewer inpatient visits was a shift towards observation care. CMS’s changing definition of observation care makes it difficult to project using data, but 77% of survey respondents expect increased utilization,

with 30% expecting an increase of at least 10%. This latter figure is by far the most extreme response of any question surveyed.

Emergency ServicesOf the areas surveyed, there was the least consensus about

the future utilization of Emergency Services. Over 40% of executives expect changes of at least 5%, but they are split on whether that will be an increase or decrease. On the whole, the respondents tended slightly towards increase, with 53% expecting some amount of growth. Of those predicting utilization increases that provided a rationale, the most common was lack of access to primary care. The executives predicting decreased utilization cited competition from urgent care centers, and better utilization of primary and specialty care.

The HCG data suggests a reduction of visits per person of around 35% between a loosely-managed population and a well-managed population. As with inpatient services, the discrepancy between the survey response and this calculated figure suggests executives are not expecting this level of dramatic change in the near future. However, unlike Inpatient Services where the overall trends were in the same direction, there was more disagreement among executives on the direction the use rate will shift in the future.

Diagnostic and Treatment ServicesRoughly, 75% of survey respondents expected changes

of less than 5% in utilization of both major imaging (CT, MRI, PET) services, and interventional labs (Cath, Electro-physiology, Interventional Radiology). A slight majority did expect some increase in Interventional Labs, resulting in an average projection of 2% growth. For major imaging the aver-age was a small fractional percentage decrease. Here again we see a large discrepancy between the survey responses and the HCGs. In this case, the data suggests that most markets have significant over utilization of Major Imaging and decreases of



Focus 31

over 50% utilization will be seen if markets fully transition from Loosely Managed to Well Managed care. Additionally, decreases in many markets could end up being around 30% for interventional procedures.

The executives expected more changes to surgical services. By asking about both inpatient and ambulatory surgery, it is clear they collectively antici-pate a shift in utilization from the former to the latter. Nearly half the respondents expect in-patient surgery to decline, with most of the rest expecting no change. Almost 80% expect an increase in ambulatory surgery, giving an average projection of 4% growth. However, de-spite this near-unanimity, it is again in conflict with the HCG data, which anticipate declines of 24% in inpatient surgery admissions, and over 40% of facility-based ambulatory sur-gery visits. These ambulatory surgery figures represent the widest discrepancy between survey response and the data model.

We agree with the respon-dents, there will be a shift of inpatient to outpatient sur-gery over time. The HCG data is a current snap shot of benchmarks from Well Man-aged and Loosely Managed markets that does not take into account the potential for additional services to be per-formed in outpatient settings over time. That being said, after conducting comparative market utilization analysis for numerous markets we have seen significant difference in the utilization of ambulatory surgical services, where arthroscopic knee surgery may have a 60% higher use rate in one market than the national median or laparoscopic cholecystectomy occurring 120% more often in another market than the national median. To that end, it is our belief that even with the shifting of surgical settings as markets transition to Well Managed ambulatory surgery use rates will decline in the future.

Ambulatory Clinics The closest we came to agreement between the executives

and the data model was in terms of Ambulatory Clinic services. The model predicts very modest declines of 3% for primary care and 11% for specialty clinics, both of which would also be offset by approximately a 2% increase in utilization due

to aging. In our survey data, less than 10% of executives projected declines in each of primary care and specialty care clinic utilization. While in both cases large majorities projected small changes, those changes were almost all positive. On average they project a 5% increase in primary care along with 3% in specialty care. It is important to note that the HCG data does not take into account the utilization of digital channels for providing ambulatory care in the future. While predicting the impact of technology on ambulatory clinic use rates is difficult; some healthcare technology experts are projecting 30-40% of visits could be conducted via telephone or through digital channels in the future.

ConclusionsThe local aspect of health-

care mean the level of healthcare utilization decreases will happen at differing paces throughout the country; however, the results of the survey show that many healthcare organizations likely do not understand the potential magnitude for utilization reduc-tions and/or believe that most healthcare organizations will not have the structures in place to

make significant changes over the next five years. It is our opin-ion that most healthcare organizations will not achieve Well Managed benchmarks over the next five years (although some will surpass them on selected metrics), but organizations should be conducting long-term planning that takes into account these types of reductions. Provider organizations will also need to

Some of the key factors that will account for organizations removing excess utilization and the associated cost are: • Programsthateducatephysiciansonways toprovide

care more efficiently

• Disease management programs that actively manage patients with chronic conditions and that are at risk

• Utilizing care teams with physician extenders to allow physicians to focus on caring for sicker, high-risk, and chronic patients

• Demand management programs that teach members when to seek medical assistance

• Changes in health plan design that incentivize patients to seek care in more appropriate settings and incentivizes healthy behaviors and preventative care

• Active use of case managers to facilitate treatment of acute and chronically ill patients, and coordinate their care

• Increased care management and changes to reimbursement models that require providers to first use less costly medical options prior to interventions

• Financial incentives that reward providers for efficient utilization and quality outcomes

• Integrated networks that coordinate the use of appropriate levels of care (e.g., post-acute, ambulatory care) and limit duplication

• Information systems that support the monitoring of utilization and compliance with evidence-based practices

• Clinical data warehouses and analytical tools that locate chronic populations and use predictive modeling to determine high-risk populations to be targeted for early intervention

• Digital channels that utilize algorithm for treatment of minor health issues and the use of telemedicine



32 Focus

consider how their asset portfolios will evolve in the future and begin to think in terms of consolidation and delivering care in alternative lower cost settings instead of planning for growth as they have been historically accustomed.

Additionally, the scale of the opportunity to remove duplication and waste and to create value will have a significant impact on most healthcare market places. The first movers to value-based delivery will have a distinct market advantage over those that continue to live in the fee-for-service world if they are able to capture the value that they are creating. Most markets have significant opportunity to lower excess utilization and medical loss. The health systems that are able to do this well will be able to go to market at a substantially lower price point and shift considerable numbers of lives and market share to their delivery network. The impact of which will accelerate the pace of consolidation in the healthcare market.

About the authorsThis report was produced in collaboration with the Health Care Group of Kurt Salmon, a global management and strategy consulting firm that enables health care organizations to realize critical strategic advancements, create value from clinical integration, transition to population health management and achieve performance improvement. For further information, visit: www.kurtsalmon.com/healthcare.

Contributions to this report were made by Milliman, among the world’s largest providers of actuarial and related products and services. The firm has consulting practices in healthcare, property & casualty insurance, life insurance and financial services, and employee benefits. Founded in 1947, Milliman is an independent firm with offices in major cities around the globe. For further information, visit www.milliman.com.

mark your calendar . . .

PLEASE NOTE: NJ HFMA offers a discount for those members who wish to attend Chapter events and who are currently seeking employment. For more information or to take advantage of this discount contact Laura Hess at [email protected] or 888-652-4362. The policy may be viewed at: http://hfmanj.orbius.com/public.assets/A02-Unemployed-Discount/file_168.pdf

January 13, 2015 Bi-MonthlyHotel Woodbridge PFS/PAS (Patient Financialat Metropark* Services/Patient Access Services)

February 5, 2015 HFMA/HIMSSHoliday Inn Collaborative SessionEast Windsor

March 10, 2015 Bi-MonthlyHotel Woodbridge CARE (Compliance, Audit, Risk & Ethics)at Metropark* & Physician Practice Management Forums

April 16, 2015 NJ HFMA Women’s SessionDoubletree Hotel Tinton Falls in Eatontown

*Formerly the Woodbridge Hilton



are usually scheduled around mid-day, so that they can truly be lunch and learn sessions. And there have been a wide range of topics, many of which are new to our agenda.

And finally, each summer for the past 3 years we’ve of-fered our Yerger Award winning 101 Series. These are basic courses in Patient Financial Services, Healthcare Finance, and Medicare for both hospitals and physician practices. Each year we’ve looked to both expand and improve upon these sessions, which are aimed at staff new to healthcare, but can also be a refresher course for those of us who have been around a few years. This past summer we added a second level of courses,

offering attractive pricing for those who chose to attend the morning and afternoon sessions, or the complete series.

As the above article illustrates, the Education Committee plays an active and vital role in our Chapter’s success. Through the Summer Sessions, Annual Institute, collaborative presen-tations, webinars and specialized programs we try to remain responsive to the needs of our members. If you have any ques-tions or comments, or would like to become involved in all that we do, please do not hesitate to reach out to me or any of the members of the committee.


Focus 33

You and Your 340B Program: Are You Compliant or Confused?

by Venson Wallin and Bill Bithoney, MD

Venson Wallin

Bill Bithoney

What is the 340B program? The 340B program is a means through which providers,

known as “covered entities,” can offer pharmaceuticals to a greater amount of eligible patients than they could at tradi-tional manufacturer pricing. This is because the program re-quires that manufacturers sell the drugs to the eligible provid-ers at a discount, thereby enabling a larger number of those in need to get the assistance they need with purchasing their prescriptions. The 340B program is very popular for this very reason; covered entities are able to purchase drug supplies at the 340B discounted price, and then bill the patient’s insur-ance company the traditional rate. This “margin” generates much needed profit for some of the more income-challenged providers, while having minimal impact on the Medicare and Medicaid program costs. The patient wins, the provider wins, and the government programs win. Providers understand the upside, and annual 340B drug spending by covered entities exceeds six billion dollars and approximately one-third of U.S. hospitals participate in the program. The spending and num-ber of participating providers is forecast to increase significant-ly during the coming years.

In 1992, Congress created the 340B program via Public Law 102-585, the Veterans Health Care Act of 1992, which is otherwise known as Section 340B of the Public Health Service Act. The law requires drug manufacturers that participate in the Medicaid program to agree to provide discounts on cov-ered outpatient drugs purchased by government-supported facilities, or “covered entities.” Examples of “covered entities” include disproportionate share hospitals, sole community hos-pitals, rural referral centers, critical access hospitals, and chil-dren’s hospitals and cancer hospitals exempt from the Medi-care prospective payment system. Enrollment periods for those providers seeking to participate in the program are open on a quarterly basis. Administration of the 340B program is per-formed by the Office of Pharmacy Affairs (OPA) of the Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services.

Achieving Compliance with 340B Program Guidelines

Compliance pertaining to a 340B program is relative. A provider may consider them-selves in compliance with the guidelines of the program based on their understanding of these guidelines, whereas HRSA and the OPA may consider the provider to be noncompliant based on their interpretation of these same guidelines. These di-vergent opinions are a result of a set of rules that are written in a somewhat general manner, excluding the detailed implemen-tation regulations that are common to other HHS programs. HRSA recognizes the need for more clarity on the part of the covered entities and is actively working to close the interpreta-tion “gap” and to achieve more compliance within the program.

HRSA has heard the rumblings from the industry and Congress over the past several years regarding the 340B pro-gram and the need for more detailed directions to minimize both unintentional violations of the program as well as inten-tional efforts to take advantage of the interpretation “gap” to prosper to an extent not anticipated by the authors of the pro-gram. Audits in recent years by HRSA and the Office of the Inspector General (OIG) of HHS have confirmed the fact that covered entities are having challenges meeting full compliance with guidelines, particularly in the areas of diversion and du-plicate discounts. Another key factor in meeting compliance requirements identified through the audits is the degree to which providers utilize contract pharmacies and their oversight of such. The use of contract pharmacies, while occurring in the minority of covered entities at this point, is growing and there is a wide disparity in their treatment and oversight. HRSA has continued on page 34


34 Focus

strongly recommended the use of independent audits of con-tract pharmacies to address compliance.

Increased Focus on Integrity and Compliance So where does one go from here? Good question and one

that the HHS OIG and HRSA intend to address in the im-mediate future. They are both being very active in publishing clarifying documents and preparing to conduct more extensive audits of 340B programs. The HHS OIG 2014 Work Plan contains initiatives pertaining to the 340B program, includ-ing a focus on contract pharmacy compliance by covered enti-ties. In February, 2014, the OPA issued a program update that addressed contract pharmacy compliance and the continued focus on the program’s integrity. In its June, 2014 program update, HRSA discussed an additional six million dollars that Congress had set aside for the 340B program. The addition-al funding is being used to establish a new branch of HRSA – Program Performance and Quality – which is tasked with overseeing program integrity. HRSA stressed that program in-tegrity has always been a focal point of their staff, but that the new branch will now enable them to devote even more empha-sis on this topic. And in its July, 2014 program update, HRSA further clarified its audit process, reaffirming its focus on in-creased audits and the intent to no longer issue preliminary audit reports but to only issue final reports. The commitment to a renewed attention to compliance through increased audits is evident through these updates and publications and covered entities would be advised to prepare for the inevitability of an increase in 340B program audits and that they may soon fall within HRSA’s radar.

“Mega-Reg” to provide clarification Many facilities may be feeling somewhat alarmed by this enhanced focus on program integrity in that they believe they may need more guidance to ensure that their program is truly compliant. As discussed before, heretofore, detailed implementation guidance on the 340B program has been found to be somewhat lacking, and compliance became an “interpretation of the rules” exercise. Now, with more expected of them, the covered entities are in need of specific clarification of the rules and HRSA is prepar-ing to provide such guidance. The much discussed “mega-reg” that HRSA is expecting to issue will provide specific guidance on issues such as the definition of an eligible patient, compli-ance requirements for contract pharmacy arrangements, hos-pital eligibility criteria, and the eligibility of off-site hospital facilities.

Throwing a potential curve into HRSA’s plans is the recent (May, 2014) decision by the United States District Court for the District of Columbia (USDCDC), which held that HRSA lacked the ability to issue the regulation regarding orphan drugs. HRSA had attempted to promulgate limitations on

the use of orphan drugs by certain covered entities; however, the USDCDC found that the 340B regulation itself limited HRSA’s ability to promulgate regulations to only those areas dealing with the administrative dispute resolution process, cal-culation of ceiling prices, and civil monetary penalties. Fur-thermore, orphan drugs were not deemed to be included in the definition of any of these three areas, therefore, HRSA was found to not have the authority to issue any regulations per-taining to them.

Covered entities may wonder why this is important if or-phan drugs are not a large part of their 340B program. The importance lies in the ability of HRSA to issue and enforce the “mega-reg.” HRSA has so far chosen not to appeal the US-DCDC finding, and it must decide, before proceeding, wheth-er the issues covered by the “mega-reg” would survive a likely court challenge in light of the USDCDC decision, and wheth-er a further “tweaking” of the regulation should occur prior to its actual issuance. At this point, HRSA has indicated that they continue to look to move forward with the “mega-reg.”

Conclusion

It is very clear that the history of the 340B program being loosely regulated and enforced is just that – history. HRSA, the OPA and the HHS OIG all have the 340B program high on their list of priorities and they are committed to ensur-ing a more consistent implementation of the program and to strengthening its integrity. Through audits and publication of clarifying guidance, they are working with covered entities to achieve those goals. Covered entities should be proactive in assessing the compliance of their 340B programs and tak-ing steps to document compliance and/or perform corrective efforts to become compliant. Steps may include performing internal assessments of policies and procedures or partnering with external agents to assist with these assessments, perform-ing audits of the program components, obtaining independent audits of contract pharmacy arrangements, and developing a routine process of monitoring new HRSA program updates and their impacts, including the new “mega-reg.” By taking these steps, covered entities can begin to move the gauge from “confusion” to “compliance.”

About the authors:Venson Wallin is a Managing Director and the National Health-care Compliance and Regulatory Leader for The BDO Center for Healthcare Excellence & Innovation. He can be reached at [email protected]. Bill Bithoney, MD, is a Managing Director and Chief Physician Executive for The BDO Center for Healthcare Excellence & In-novation, where he co-leads Clinical Strategy. He can be reached at [email protected].


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